Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 04
This report estimates subtotals of units and fees for the number of days of overlap between each included
FSPSA record and the user-selected report period. For example, if the FSPSA record authorizes services from
01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01). Note that service authorization periods
may range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs overlapping: 10-01-13 and 12-31-13 Date of Report: 02-18-14 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Service Coordination, Class # 01
SCONLY-SCONLY SERVICE COORDINATION ONLY 16 16 20.072223 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 16 16 20.072223 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 26 29 10.596497 $513.9200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.111111 $5.0300 $45.2800
AUDE -AUDE UNSPECIFIED AUDE SERVICES 1 1 1.022222 $61.3300 $60.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.511111 $23.0000 $45.0000
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 1 1 3.066667 $92.0000 $30.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 6 9 2.711111 $131.4900 $48.5000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 5 1.544444 $74.9000 $48.5000
SPCH -92506 SPEECH EVAL BY LICENSED SLP 3 3 12.175397 $590.5100 $48.5000
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Subtotal (Total Children Is Unduplicated) 40 50 31.738560 $1492.1800 $47.0100
EI Services, Class # 03
AUD -HA_FUP AUDIOLOGY SERVICES 8 11 46.411906 $2320.6000 $50.0000
CONIF -CONIF CONSULT ITDS, FACE TO FACE 1 2 0.177778 $8.8900 $50.0100
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 34 22.388887 $1119.4400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 61 37.144440 $1857.2000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 10 12 14.049999 $702.5000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 31 41 271.990473 $13599.5400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 11 88.571428 $6012.2300 $67.8800
PHY -97110 PT SESSION BY LICENSED PT 8 9 76.999999 $5226.7700 $67.8800
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 4 2.038889 $132.5300 $65.0000
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 3 4 10.038096 $501.9100 $50.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 1.714286 $116.3700 $67.8800
TRAV -FLAT PROV TRAVEL TO NATL ENV $10 PER CHI 1028 1506 16375.272106 $163752.8600 $10.0000
TRAV -TRAV PROV TRAVEL TO NATURAL ENV PER MINU 8 8 81.142856 $40.5700 $0.5000
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Subtotal (Total Children Is Unduplicated) 1047 1705 17027.941143 $195391.4000 $11.4700
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Total 1771 17079.751926 $196883.5800 $11.5300
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Number of Children (Unduplicated) With at Least One Authorization 1071